Single-dose intraoperative radiotherapy during lumpectomy for breast cancer: an innovative patient-centred treatment

SUMMARY In the randomised TARGIT-A trial, risk-adapted targeted intraoperative radiotherapy (TARGIT-IORT) during lumpectomy was non-inferior to whole-breast external beam radiotherapy, for

local recurrence. In the long-term, no difference was found in any breast cancer outcome, whereas there were fewer deaths from non-breast-cancer causes. TARGIT-IORT should be included in

pre-operative consultations with eligible patients. MAIN In 1996, the _British Journal of Cancer_ published original work from our group, describing widespread spatial distribution of

additional cancer foci in mastectomy specimens of patients who were otherwise suitable for breast conservation.1 We proposed that these foci may not be clinically relevant because of local

recurrence after breast conservation occurs mainly at the site of primary tumour. The TARGIT-A randomised trial2 was firmly rooted in this initial observation, and compared risk-adapted

single-dose targeted intraoperative radiotherapy (TARGIT-IORT) given during lumpectomy vs conventional whole-breast external beam radiotherapy (EBRT) in an international randomised

non-inferiority trial. The long-term results of the randomised TARGIT-A trial were recently published.3 They confirmed comparable long-term effectiveness of risk-adapted TARGIT-IORT and EBRT

in terms of breast cancer control. At 5-years complete follow-up, for the primary outcome of absolute difference in raw local-recurrence rates was 1.16% with the upper 90% confidence limit

of 1.99%, confirming non-inferiority at the prespecified margin of 2.5%. With long-term follow-up (median 9 years, maximum 19 years), no statistically significant difference was found in

local or distant control of breast cancer, breast-preservation or breast cancer mortality. Deaths from causes other than breast cancer were significantly fewer in the TARGIT-IORT arm—HR 0.59

(0.40–0.86) _P_ = 0.005, with 12-year rates being 5.41 vs 9.85%, a reduction of 4.44%. In this commentary we would like to address a number of critical points. * (1) The first of these is

to emphasise that TARGIT-A trial was not restricted only to patients with a very low risk of local recurrence. Participants had a much higher risk profile than with other trials of partial

breast irradiation (PBI, Table 13,4,5,6,7,8,9,10,11). These other trials restricted the trial entry much more stringently, only recruiting patients with the best prognostic features. By

contrast, a substantial absolute number of patients in TARGIT-A, just like the Fast-Forward trial of shorter-course whole breast radiotherapy (Table 2)12 were at higher risk of relapse: 1898

(83%) were younger than 70 years, 366 (16%) had tumours >2 cm in size, 443 (20%) patients had grade 3 cancers, 488 (22%) patients had involved nodes and 426 (19%) had ER- or PgR-negative

tumours. Similarly, patients in the three main trials comparing radiotherapy vs no-radiotherapy (Table 2—CALBG, BASO-II and PRIME-II),13,14,15,16 were again very highly selected for their

low-recurrence risk. By contrast with TARGIT-A, they were strictly limited to those older than 65 or 70 years, with smaller, lower grade, node negative and ER-positive tumours. Despite this,

the 5-year local-recurrence rates with ‘no-radiotherapy’ were 2–3 times higher than those seen with TARGIT-IORT (Table 2). For the record, most patients in the TARGIT-A trial who had

high-risk features did not receive supplemental EBRT after TARGIT-IORT as part of the risk-adapted approach. For example, supplemental EBRT was not given to 78% of Grade 3, not given to 82%

of ER-negative and not given to 63% of node-positive patients. Rather, the decision regarding use of supplemental EBRT was made for the individual patient by the treating multidisciplinary

team, particularly bearing in mind the main indications of unexpected lobular cancer and positive margins. We regard this as a more patient-centred approach, which takes account of the

individual patient-specific circumstances, including their preferences. What does all this add up to? Data from the TARGIT-A trial suggest that PBI using this risk-adapted TARGIT-IORT

approach is applicable to a breast cancer population more widely inclusive than those recruited in other PBI or ‘no-radiotherapy’ trials. By having TARGIT-IORT during their lumpectomy, 8 out

of 10 patients complete their radiotherapy right away, and the benefits include avoiding repeated hospital visits,17 a generally lower toxicity, and an improved quality of

life.18,19,20,21,22,23 * (2) An important statistical point relates to the use of Kaplan–Meier (K–M) curves. These are very informative if properly computed. The first step for estimating

the risk of any event (e.g. local recurrence), is to categorise each patient into either having the event or not. The time-to-event is then used to plot a graph. This would work well if

everyone’s follow-up was the same and no one died, but this of course is never the case because patients are never recruited all at the same instant in any trial. The K–M model therefore

uses a method called ‘censoring’, which means that a patient’s data are used until the point when they were last seen. The assumption is that they are alive after they were last seen and

continue to have a risk of having local recurrence. But, sadly, some patients die during follow-up, at which point this assumption is of course no longer true. So, when plotting K–M

estimates for local recurrence, one should not categorise patients who have died as ‘censored’. Such a plot _must include death_ as an event.3 Both the plot and any estimate in which the

dead have been censored are set in an imaginary world where there is a continual risk of local recurrence after death. Unfortunately, such graphs have frequently been published and are

inevitably misleading to readers. Here is an example to make this clearer. Let’s look at the NSABP-B39 data.24 Their K–M graph of local recurrence shows that the chance of having local

recurrence with PBI at 10 years is 4.6%, therefore 95.4% of patients can be expected to be local-recurrence free. This immediately leads to a paradox because in fact, only 90.6% are alive at

10 years, so how can a larger number of patients (95.4%) be around (alive) to be local-recurrence free? A further example comes from the CALGB trial,14 in which over 90% patients are

estimated to be alive without local recurrence at 10 years, when in fact only 60% are actually alive. Thus, such a K–M graph allegedly depicting local control over time is misleading. For

this reason both DATECAN25 (European) and STEEP26 (American) guidelines, rightly insist that death and local recurrence should both be included as clinical events for assessing local

treatments for breast cancer. Most importantly of all, patients naturally need to know the local control achieved by any new approach compared with the previous standard, which is precisely

provided by the outcome of local-recurrence-free survival. * (3) Next, we would like to discuss the persistent finding of fewer non-breast cancer deaths with TARGIT-IORT, compared with

whole-breast radiotherapy. The reduction was mainly due to fewer deaths from cardiovascular or lung problems and from other cancers and was not small in magnitude: 41% in relative terms and

4.4% at 12 years in absolute terms. Randomisation, especially when the trial size is large, ensures that both known and unknown factors are well balanced. In the TARGIT-A trial, all known

prognostic factors3 were well balanced, as well as age and body mass index (BMI),3 relevant for risks of cardiovascular27 and malignant disease.28 This somewhat surprising observation is in

fact consistent with the results of meta-analyses of randomised trials comparing partial breast irradiation with whole-breast irradiation.29,30 It is well to remember that even modern

radiotherapy increases cardiac and lung cancer mortality.31,32,33,34,35 This is particularly important in current or ex-smokers,31 in which a survival decrement of 6% is estimated over a 30

year period. This detriment is likely to outweigh any possible survival benefit from radiotherapy for these patients with early breast cancer.36 Perhaps even more important nowadays, in

patients with screen-detected cancer, where the dangers of overtreatment are now so well recognised,37 we argue that it is both logical and in the patient’s interest to use TARGIT-IORT, in

order to minimise side effects. * (4) Finally, it is obvious that this work has special relevance during the current COVID-19 pandemic during which additional visits for radiotherapy

consultations, planning and treatment all raise the risks to a vulnerable population as well as adding to pressures on an overstretched hospital system. TARGIT-IORT could help reduce these

risks and save precious resources. CONCLUSION Using the approach of risk-adapted TARGIT-IORT in patients with early breast cancer avoids the inconvenience and toxicity of whole-breast

radiotherapy in 8 out of every 10 patients. When compared with whole-breast radiotherapy in the randomised TARGIT-A trial, now with long-term follow up, no difference was found for any

breast cancer outcomes, but there was a reduction in non-breast cancer mortality with TARGIT-IORT. Previous studies have shown that the other advantages include reduced breast pain, a better

quality of life,18,19,20,21,22,23 a cosmetically superior outcome and reduced travelling time for the patient.17 Clinicians and patients in 38 countries (260 centres) have been adopting

TARGIT-IORT since the publication of the first results, and over 45,000 patients have been treated so far. We believe that the long-term data,3 taken together with the many obvious benefits

for the patient, provide compelling evidence to roll this out further. Finally, all doctors in the UK are now obliged to follow the recently published GMC guidelines which underline the

essential nature of adequate patient information—i.e. what they can reasonably expect to be told—in order to provide valid consent

(https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/consent). This powerful principle is now fully enshrined in UK law (Montgomery v Lanarkshire Health Board, 2015).

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using 3-dimensional conformal external beam radiation therapy. _Adv. Radiat. Oncol._ 5, 171–179 (2020). PubMed  Google Scholar  Download references ACKNOWLEDGEMENTS NA TARGIT-A TRIAL AUTHORS

Jayant S. Vaidya1, Max Buslara2, Michael Baum1, Frederik Wenz4, Samuele Massarut5, Steffi Pigorsch6, Michael Alvarado7, Michael Douek8, Christobel Saunders9, Henrik L. Flyger10, Wolfgang

Eiermann6, Chris Brew-Graves1, Norman R. Williams1, Ingrid Potyka1, Nicholas Roberts1, Marcelle Bernstein11, Douglas Brown12, Elena Sperk4, Siobhan Laws13, Marc Sütterlin14, Tammy Corica15,

Steinar Lundgren16,17, Dennis Holmes18, Lorenzo Vinante19, Fernando Bozza20, Montserrat Pazos21, Magali Le Blanc-Onfroy22, Günther Gruber23, Wojciech Polkowski24, Konstantin J. Dedes25,

Marcus Niewald26, Jens Blohmer27, David McCready28, Richard Hoefer29, Pond Kelemen30, Gloria Petralia31, Mary Falzon3,32, David J. Joseph15, Jeffrey S. Tobias3 AUTHOR INFORMATION AUTHORS AND

AFFILIATIONS * Division of Surgery and Interventional Science, University College London, London, UK Jayant S. Vaidya, Max Bulsara, Michael Baum, Chris Brew-Graves, Norman R. Williams, 

Ingrid Potyka & Nicholas Roberts * Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia Max Bulsara * Department of Clinical Oncology, University College

London Hospitals, London, UK Jeffrey S. Tobias & Mary Falzon * Department of Radiation Oncology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University,

Heidelberg, Germany Frederik Wenz & Elena Sperk * Department of Surgery, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy Samuele Massarut * Department of

Gynaecology and Obstetrics, Red Cross Hospital, Technical University of Munich, Munich, Germany Steffi Pigorsch & Wolfgang Eiermann * Department of Surgery, University of California, San

Francisco, CA, USA Michael Alvarado * Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK Michael Douek * School of Surgery, University of Western Australia, Crawley,

WA, Australia Christobel Saunders * Department of Breast Surgery, University of Copenhagen, Copenhagen, Denmark Henrik L. Flyger * London, UK Marcelle Bernstein * Department of Surgery,

Ninewells Hospital, Dundee, UK Douglas Brown * Department of Surgery, Royal Hampshire County Hospital, Winchester, UK Siobhan Laws * Department of Gynaecology and Obstetrics, University

Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany Marc Sütterlin * Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA,

Australia Tammy Corica & David J. Joseph * Department of Oncology, St Olav’s University Hospital, Trondheim, Norway Steinar Lundgren * Department of Clinical and Molecular Medicine,

Norwegian University of Science and Technology, Trondheim, Norway Steinar Lundgren * University of Southern California, John Wayne Cancer Institute & Helen Rey Breast Cancer Foundation,

Los Angeles, CA, USA Dennis Holmes * Department of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy Lorenzo Vinante * Veneto Institute of Oncology

IOV - IRCCS, Padua, Italy Fernando Bozza * Department of Radiation Oncology, University Hospital, The Ludwig Maximilian University of Munich, Munich, Germany Montserrat Pazos *

Radiotherapy-Oncology, Western Cancer Institute, Nantes, France Magali Le Blanc-Onfroy * Breast Centre Seefeld, Zurich, Switzerland Günther Gruber * Department of Surgical Oncology, Medical

University of Lublin, Lublin, Poland Wojciech Polkowski * Breast Centre, University Hospital Zurich, Zurich, Switzerland Konstantin J. Dedes * Saarland University Medical Center, Homberg,

Germany Marcus Niewald * Sankt Gertrauden Hospital, Charité, Medical University of Berlin, Berlin, Germany Jens Blohmer * Princess Margaret Cancer Centre, Toronto, ON, Canada David McCready

* Sentara Surgery Specialists, Hampton, VA, USA Richard Hoefer * Ashikari Breast Center, New York Medical College, New York, NY, USA Pond Kelemen * Department of Surgery, University College

London Hospitals, London, UK Gloria Petralia * Department of Pathology, University College London Hospitals, London, UK Mary Falzon Authors * Jayant S. Vaidya View author publications You

can also search for this author inPubMed Google Scholar * Max Bulsara View author publications You can also search for this author inPubMed Google Scholar * Michael Baum View author

publications You can also search for this author inPubMed Google Scholar * Jeffrey S. Tobias View author publications You can also search for this author inPubMed Google Scholar CONSORTIA ON

BEHALF OF THE TARGIT-A TRIAL AUTHORS * Jayant S. Vaidya * , Max Bulsara * , Michael Baum * , Frederik Wenz * , Samuele Massarut * , Steffi Pigorsch * , Michael Alvarado * , Michael Douek *

, Christobel Saunders * , Henrik L. Flyger * , Wolfgang Eiermann * , Chris Brew-Graves * , Norman R. Williams * , Ingrid Potyka * , Nicholas Roberts * , Marcelle Bernstein * , Douglas Brown

* , Elena Sperk * , Siobhan Laws * , Marc Sütterlin * , Tammy Corica * , Steinar Lundgren * , Dennis Holmes * , Lorenzo Vinante * , Fernando Bozza * , Montserrat Pazos * , Magali Le

Blanc-Onfroy * , Günther Gruber * , Wojciech Polkowski * , Konstantin J. Dedes * , Marcus Niewald * , Jens Blohmer * , David McCready * , Richard Hoefer * , Pond Kelemen * , Gloria Petralia

* , Mary Falzon * , David J. Joseph *  & Jeffrey S. Tobias CONTRIBUTIONS J.S.V. wrote the first draft, made important intellectual contribution to the conceptualisation, data analysis,

data interpretation, writing and editing the manuscript and agreed with the final version. M.Bu. made important intellectual contributions towards conceptualisation, data analysis, data

interpretation, writing and editing. M.Ba. and J.S.T. made important intellectual contribution towards conceptualisation, data interpretation, writing and editing. J.S.V., M.Bu., M.Ba. and

J.S.T. agreed with the final version of the manuscript. CORRESPONDING AUTHOR Correspondence to Jayant S. Vaidya. ETHICS DECLARATIONS ETHICAL APPROVAL AND CONSENT TO PARTICIPATE OR PUBLISH

Not applicable. CONSENT TO PUBLISH Not applicable. DATA AVAILABILITY Not applicable. COMPETING INTERESTS We declare support from University College London Hospitals (UCLH)/UCL Comprehensive

Biomedical Research Centre, UCLH Charities, National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme, Ninewells Cancer Campaign, National Health and Medical

Research Council, and Cancer Research Campaign (now Cancer Research UK) for the submitted work; J.S.V. has received a research grant from Photoelectron Corp (1996–1999) and from Carl Zeiss

for supporting data management at the University of Dundee (Dundee, UK, 2004–2008), and has received honorariums. J.S.V., J.S.T. and M.B.u. receive funding from HTA, NIHR, Department of

Health and Social Care for some activities related to the TARGIT trials. M.B.a. was briefly on the scientific advisory board of Carl Zeiss and was paid consultancy fees before 2010. All

authors received some travel support from Carl Zeiss. Carl Zeiss had no role in concept, design, analysis or writing of the manuscript. FUNDING INFORMATION No specific funding was made

available for this paper. The TARGIT-A trial was sponsored by University College London Hospitals (UCLH)/UCL Comprehensive Biomedical Research Centre. Funding was provided by UCLH Charities,

National Institute for Health Research (NIHR) Health Technology Assessment programme (HTA 07/60/49), Ninewells Cancer Campaign, National Health and Medical Research Council, and German

Federal Ministry of Education and Research (BMBF) FKZ 01ZP0508. The infrastructure of the trial operations office in London, UK was supported by core funding from Cancer Research Campaign

(now Cancer Research UK) when the trial was initiated. The funding organisations had no role in concept, design, analysis or writing of the manuscript. ADDITIONAL INFORMATION PUBLISHER’S

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ARTICLE Vaidya, J.S., Bulsara, M., Baum, M. _et al._ Single-dose intraoperative radiotherapy during lumpectomy for breast cancer: an innovative patient-centred treatment. _Br J Cancer_ 124,

1469–1474 (2021). https://doi.org/10.1038/s41416-020-01233-5 Download citation * Received: 09 October 2020 * Revised: 04 December 2020 * Accepted: 11 December 2020 * Published: 02 February

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